New guidance from the Brazilian Psychiatric Association places psychotherapy at the center of treatment for bulimia nervosa, binge-eating disorder and anorexia nervosa. Medication may have a role, but the recommendations describe it as part of broader care rather than a substitute for therapy.
The guidance was developed mainly for clinicians working in Brazil’s public health system and covers adults and adolescents. It was based on searches of six databases through June 30, 2025, with systematic reviews and meta-analyses prioritized and randomized trials used where evidence was missing.
Recommendations were agreed at five expert meetings, with more than 75% agreement required for each recommendation. The document is an accepted pre-proof, meaning some details could change before final editing and publication.
Psychotherapy leads care
The guideline uses evidence levels to describe the kinds of studies supporting a statement. Level 1 refers to systematic reviews of randomized trials, while Level 2 refers to individual randomized trials. Lower levels include nonrandomized studies, case series and expert reasoning.
Those levels describe the type of evidence, not how effective a treatment is. The authors also note that the recommendations reflect expert consensus and the realities of Brazil’s public health system.
Binge-eating disorder
Clinician-led cognitive behavioral therapy, or CBT, is the recommended first treatment. In the evidence reviewed, it led to remission of binge eating in 48% to 53% of patients, with benefits lasting as long as 24 months.
Guided CBT self-help is an option when access to a therapist or consistent participation is limited. It produced remission in 42% to 46% of patients. Interpersonal therapy and dialectical behavior therapy may be considered when CBT is unavailable or has not worked, with reported remission rates ranging from 33% to 63%.
Behavioral weight-loss programs had smaller and less durable effects in the reviewed evidence, with remission ranging from 23% to 41%. The guideline also recommends regular, structured meals and snacks, education about hunger and fullness cues, and gradual supported exposure to feared foods.
When medication is needed, lisdexamfetamine is listed as the preferred option. Pooled data from three randomized trials found that it reduced binge frequency and increased remission, with medium-sized effects. It did not significantly improve depressive symptoms.
Topiramate may be considered off-label for selected patients, including those with a higher body mass index or limited response to first-line treatment. Selective serotonin reuptake inhibitors, including fluoxetine and sertraline, reduced binge frequency and depressive symptoms in the reviewed studies.
GLP-1 medicines such as semaglutide and liraglutide showed early promise in small, short studies, but the guideline does not consider them established first-line treatments for binge-eating disorder.
Bulimia nervosa
For mild to moderate bulimia, guided CBT self-help is recommended first. About one-third of patients in the reviewed evidence stopped binge eating and purging during treatment, although 14.7% remained symptom-free after treatment ended.
Individual CBT adapted for eating disorders, known as CBT-ED, is recommended when self-help is insufficient and is the starting treatment for severe bulimia. It had the highest remission rates among the approaches reviewed.
Other therapies—including behavioral therapy, interpersonal therapy, dialectical behavior therapy, family-based therapy and psychodynamic therapy—may be used when CBT-ED is unavailable or unsuitable.
Fluoxetine at 60 mg per day is identified as the first-line add-on medication. The guideline describes it as an addition to therapy, not a stand-alone treatment. It is the most studied medication for bulimia and the only medication approved for the condition by Brazil’s regulator, ANVISA, according to the guidance.
Topiramate may be considered in selected cases, with attention to possible cognitive side effects. Ondansetron is reserved for exceptional cases that have not responded to other treatment. The guideline advises against bupropion because of seizure risk and does not recommend trazodone, mirtazapine, naltrexone, spironolactone or lithium for bulimia because they have not shown efficacy.
Anorexia nervosa has fewer clear answers
For anorexia nervosa, the guideline does not identify one psychotherapy as clearly superior. Enhanced CBT, MANTRA and specialist supportive clinical management each improved eating-disorder symptoms, but no clear winner emerged.
The recommended approach combines nutritional rehabilitation under medical supervision with specialist psychotherapy. The goals are to restore weight, reduce eating-disorder symptoms and help the person remain in treatment. Psychotherapy should be manual-based, adapted to the individual and delivered by clinicians experienced in eating disorders.
In adult trials, individual family therapy was about 3.5 times as likely as usual care to result in remission or clinical improvement. CBT and CBT-E also had lower dropout rates than comparison treatments, with an odds ratio of 0.54.
Medication has a limited supporting role. Systematic reviews do not support antidepressants for weight gain or core anorexia symptoms, and drug studies are generally small, short and often lack placebo controls. Olanzapine may be added to therapy in selected severe cases because of a small effect on weight gain, but it is not approved for anorexia and requires monitoring of blood sugar and lipids.
Choosing the level of care
The guideline recommends the least restrictive setting that can keep a person safe. Decisions should be made case by case, considering medical risk, symptom severity and social support.
Bulimia and binge-eating disorder are usually treated as outpatient conditions. More intensive care may be needed when symptoms are severe, medical or psychiatric problems are serious, or outpatient treatment has not worked. For anorexia, the reviewed evidence found no clear difference in weight restoration or symptoms between full-time inpatient care, outpatient care and partial hospitalization, although the appropriate setting still depends on individual safety needs.
Important limits of the guidance
- The document is a pre-proof and may change before final publication.
- It excludes children, pregnant women and older adults.
- It does not cover avoidant/restrictive food intake disorder, prevention, screening or assessment.
- Many underlying studies had small samples, short follow-up, substantial reliance on self-report and limited representation of men, adolescents and ethnic minorities.
- The source notes an unresolved inconsistency about naltrexone-bupropion in binge-eating disorder: a summary table mentions it during maintenance, while the main text says it does not reduce binge frequency or improve remission.
The guidance says its recommendations are consistent with existing international guidelines, including the 2023 American Psychiatric Association guideline. For anyone affected by an eating disorder, the practical message is that treatment should be individualized and coordinated by clinicians with relevant expertise, rather than based on medication alone or on a single “best” approach.
AI tools were used to assist with the preparation of this article.
Leave a Reply